SOAP Note and Differential Diagnoses for IHuman Case Carolyn Cross V3 (1 Solved Case)

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SOAP Note and DifferentialDiagnoses for iHuman Case"Carolyn Cross V3withcomplete solution

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SOAP Note and Differential Diagnoses for iHuman Case "Carolyn Cross V3Name: Carolyn CrossDate: 05/21/2018Time: 1020 AMAge: 41 y /oSex: FBMI (27.5)Height 5’ 3’’Weight 155 poundsSUBJECTIVECC:HPI:Ms. Cross is a healthy 41-year-old G2P2 Hispanic-American female who presents fora well-woman examination. She has no active medical complaints, but is concerned abouther risk of breast cancer as both her mother (age 63) and maternal first cousin (age 44) havebeen recently diagnosed with intraductal breast cancer.She performs self-breast examines,no lumps or bumps or discharged noted by patient. She reports breast tenderness around hermenstrual cycle.Medications: Current Medications:She takes vitamin E for fibro cystic breast disease,she had a mammogram 18 months ago.PMH:Denies any health problems past or present, she had a mammogram 18 months ago.Allergies:N/AMedication Intolerances:“None at this time”Chronic Illnesses/Major traumas. M. O.Denies any chronic illness or Major traumas atthis timeOther:Immunization: Immunizations are up to date.Family HistoryShe is concerned about her risk for breast cancer and does this fact increase her risk ofbreast cancer, her mother at 63 years old and first cousin 44 year old was recentlydiagnosed with breast cancer.Father has hyperlipidemia and HTN.Social History (SH):Pt has a glass of wine every night. Her supper diet is traditionalHispanic diet. She has two sons and a husband with no reported siblings. She gardens anddoes house work for exercise.

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ROSGeneralDenies cough, night sweats. No recent weightagain. Or weight loss. Completed 2018.CardiovascularPatient denies chest pain, no murmurs,bruits, palpitations, orthopnea or edemaHeart –when palpating for PMI (Point ofMaxima/ Impact), the PMI is in the 5thintercostal space (ICS) at the mid-clavicularline (MCL)_SkinThe skin is warm and dry. No rash, bruisingor cuts to skin and abnormal hair and nailgrowth.Blanching observed for Quincke’s test.RespiratoryDenies “cough, hemoptysis, SOB,pneumonia, wheezing and an exposure toTB”EyesPt denies using glasses.Red reflex bilaterallyOptic disks sharpGastrointestinalDenies “N/V/D, constipation, Abdominalpain, hemorrhoid, eating disorder”EarsNormal appearing external structures; nodeformities or edema.No discharge notedNormal-appearing external auditory canals.Tympanic membrane translucent, non-injected and pinkish-gray in color.No scarring, discharge or purulence noted.Normal landmarks. Normal mobility withinsufflation.Genitourinary/GynecologicalNormal extemal genitaliaParous introitusNormal vaginal mucosa• Cervical eversion (ectropion) withoutfriability; samples collected for Pap smearNo abnormal dischargeUterus firm, slightly irregular in contour perbimanual exam• Adnexa difficult to palpate, nontenderNose/Mouth/Throat“Denies hoarseness, sinus problems, nosebleeding”No discharge or polypsNo edema or tenderness over the frontal ormaxillary sinuses.MusculoskeletalNo asymmetry or deformity of the backNo tenderness or spasm of the paraspinalmusclesNo localized tenderness of the spinousprocesses or pelvic structures.Musculoskeletal - test Strength is 5/5bilaterally (MRC scale; 0=completeparalysis; 5= normal power)BreastNormal, symmetrical breast contourNo visible skin or nipple abnormalitiesNo spontaneous or expressed nippledischarge or bloodIrregular "lumpy bumpy" consistencythroughout both breasts; no suspicious,discrete palpable lesionsSlight, diffuse tenderness to exam reportedNeurologicalDenies any neurological defect at this time.

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